Reinforcing outpatient medical student learning using brief computer tutorials: the Patient-Teacher-Tutorial sequence

Background:At present, what students read after an outpatient encounter is largely left up to them. Our objective was to evaluate the education efficacy of a clinical education model in which the student moves through a sequence that includes immediately reinforcing their learning using a specifically designed computer tutorial. Methods: Prior to a 14-day Pediatric Emergency rotation, medical students completed pre-tests for two common pediatric topics: Oral Rehydration Solutions (ORS) and Fever Without Source (FWS). After encountering a patient with either FWS or a patient needing ORS, the student logged into a computer that randomly assigned them to either a) completing a relevant computer tutorial (e.g. FWS patient + FWS tutorial = "in sequence") or b) completing the non-relevant tutorial (e.g. FWS patient + ORS tutorial = "out of sequence"). At the end of their rotation, they were tested again on both topics. Our main outcome was post-test scores on a given tutorial topic, contrasted by whether done in- or out-of-sequence Results:Ninety-two students completed the study protocol with 41 in the 'in sequence' group. Pre-test scores did not differ significantly. Overall, doing a computer tutorial in sequence resulted in significantly greater post-test scores (z-score 1.1 (SD 0.70) in sequence vs. 0.52 (1.1) out-of-sequence; 95% CI for difference +0.16, +0.93). Students spent longer on the tutorials when they were done in sequence (12.1 min (SD 7.3) vs. 10.5 (6.5)) though the difference was not statistically significant (95% CI diff: -1.2 min, +4.5). Conclusion: Outpatient learning frameworks could be structured to take best advantage of the heightened learning potential created by patient encounters. We propose the Patient-Teacher-Tutorial sequence as a framework for organizing learning in outpatient clinical settings

Disparities in Rate, Triggers, and Management in Pediatric and Adult Cases of Suspected Drug-Induced Anaphylaxis in Canada

INTRODUCTION: Data is sparse on drug-induced anaphylaxis (DIA) and there have not been studies assessing the differences in clinical characteristics and management of DIA between adults and children. OBJECTIVE: We assessed the percentage, diagnosis, and management of DIA among all anaphylaxis visits in three pediatric and one adult emergency departments (ED) across Canada. METHODS: Children presenting to the Montreal Children\u27s Hospital (MCH), British Columbia Children\u27s Hospital (BCCH), and Children\u27s Hospital at London Health Sciences Center and adults presenting to Hôpital du Sacré-Coeur with anaphylaxis were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized data form documenting the reaction and management was completed and patients were followed annually to determine assessment by allergist and use of confirmatory tests. RESULTS: From June 2012 to May 2016, 51 children were recruited from the pediatric centers and 64 adults from the adult center with drug-induced anaphyalxis. More than half the cases were prospectively recruited. The percentage of DIA among all cases of anaphylaxis was similar in all three pediatric centers but higher in the adult center in Montreal. Most reactions in children were triggered by non-antibiotic drugs, and in adults, by antibiotics. The majority of adults and a third of children did not see an allergist after the initial reaction. In those that did see an allergist, diagnosis was established by either a skin test or an oral challenge in less than 20% of cases. CONCLUSIONS: Our results reveal disparities in rate, culprit, and management of DIA in children versus adults. Further, most cases of suspected drug allergy are not appropriately diagnosed. Guidelines to improve assessment and diagnosis of DIA are required

Emergency Management of Pediatric Anaphylaxis due to an Unknown Cause: A 5-year follow-up study in Canada

Rationale There is limited data regarding treatment and management of anaphylaxis due to unknown causes (AUC). This study aims to assess the socio-demographics, clinical characteristics and management of pediatric AUC cases across Canada. Methods Data on 204 pediatric AUC cases were prospectively collected between 2011 and 2017 in emergency rooms at 5 centres across Canada (Montreal Children’s Hospital, Sacré-Coeur Hospital, Sainte-Justine Hospital, Janeway Children’s Hospital and BC Children’s Hospital) as part of the Cross-Canada Anaphylaxis Registry (C-CARE). Severe cases were defined as ones that manifested as cyanosis, hypoxia (saturation \u3c92%), respiratory arrest, hypotension, dysrhythmia, confusion or loss of consciousness. A primary analysis was done using multivariate logistic regression to identify factors associated with epinephrine treatment. Results Among 204 cases of AUC, 54.5% were males, and the median age was 9.1 years (IQR: 5.1, 14.4). 18.2% (95%CI 13.3%, 24.4%) had asthma, and 43.3% (95%CI 36.5%, 50.5%) had a known food allergy. 37.7% (95%CI 30.8%, 45.0%) of cases were severe. Epinephrine was not administered in 27.1% (95%CI 21.2%, 33.8%) of cases. Epinephrine auto-injector was prescribed to 79.6% (95%CI 73.2%, 84.8%) of cases and 75.4% (95%CI 68.9%, 81.1%) were referred to an allergist. Anaphylactic reactions occurring at home were more likely to be managed without epinephrine (adjusted OR for age, sex, and presence of asthma: 2.4 (95%CI 1.1, 4.7). Conclusions Our findings highlight the need to increase awareness of appropriate management of AUC with epinephrine followed by consultation with an allergist. It is possible that cases of AUC occurring outside the home have greater accessibility to epinephrine